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Top News

Athenahealth acquires EHR optimization vendor Praxify Technologies for $63 million. The six year-old company employs 80 at its office in Palo Alto, CA and maintains a development presence in India. Athenahealth CTO Prakash Khot is enthusiastic about the benefits Praxify’s machine learning and natural language-processing capabilities will bring to the company’s cloud-based products. Praxify is perhaps best known for its Mira voice-enabled charting technology.

Reader Comments

From AirStrip Technologies CEO Alan Portela: “Re: Rumored NantHealth acquisition. AirStrip has not been acquired and continues to gain momentum in the industry. AirStrip has formed a strategic alliance and commercial agreement with NantHealth that leverages synergies between the AirStrip One mobile interoperability platform and the Nant platform, particularly in the areas of data aggregation, normalization, real-time data streaming and visualization. Our alliance will focus initially on supporting clinical workflows in acute-care settings, with a gradual move toward post-acute and community-based care settings.”

From GraySky: “Re: Athenahealth/Medhost deal. Athenahealth is in due diligence conversations to acquire all or part of the Medhost products. It’s looking to get access to the small community and rural hospital market that Medhost has access to with its inpatient and ED solutions. Cerner officially passed up Medhost late last year after doing due diligence. Valuation was too high in the area of $200M-$400M. Shrinking customer base that includes only a few large customers that are evaluating conversion to Cerner or Epic. Aging product suite.” Athenahealth declined to confirm or deny.

HIStalk Announcements and Requests

This week on HIStalk Practice: Siemens Healthineers finalizes its acquisition of Medicalis. Merritt Hawkins releases its annual physician recruitment/salary report. Mindcotine hopes to use virtual reality to help smokers kick the habit. Brad Boyd outlines ways to leverage MACRA to support long-term strategic goals in the Consultant’s Corner. Plaintiff dismisses lawsuit against MDLive. Hematology-Oncology Associates of Central New York nearly suffers a $250k loss due to clerical error. Salus Telehealth finds an untapped telemedicine market in summer music tours. EClinicalWorks adds telemedicine capabilities to its app. Thanks for reading.

Webinars

June 22 (Thursday) 1:00 ET. “Social Determinants of Health.” Sponsored by Philips Wellcentive. Presenter: David Nash, MD, MBA, dean, Jefferson College of Population Health. One of the nation’s foremost experts on social determinants of health will explain the importance of these factors and how to make the best use of them.

June 29 (Thursday) 2:00 ET. “Be the First to See New Data on Why Patients Switch Healthcare Providers.” Sponsored by Solutionreach. As patients pay more for their care and have access to more data about cost and quality, their expectations for healthcare are changing. And as their expectations change, they are more likely to switch providers to get them met. In this free webinar, we’ll look at this new data on why patients switch and what makes them stay. Be one of the first to see the latest data on why patients leave and what you can do about it.

July 11 (Tuesday) 1:00 ET. “Your Data Migration Questions Answered: Ask the Expert Q&A Panel.” Sponsored by Galen Healthcare Solutions. Presenters: Julia Snapp, manager of professional services, Galen Healthcare Solutions; Tyler Suacci, principal technical consultant, Galen Healthcare Solutions. This webcast will give attendees who are considering or in the process of replacing and/or transitioning EHRs the ability to ask questions of our experts. Our moderators have extensive experience in data migration efforts, having supported over 250+ projects, and migration of 40MM+ patient records and 7K+ providers. They will be available to answer questions surrounding changes in workflows, items to consider when migrating data, knowing what to migrate vs. archive, etc.

People

Digital diagnostics services company Analyte Health appoints Kevin Weinstein (Valence Health) CEO. Former CEO Frank Cockerill, MD will take on the position of CMO.

Announcements and Implementations

Einstein Healthcare Network (PA) selects Teladoc to help it jumpstart a telemedicine program that will initially focus on the health system’s 8,500 employees.

Rush University Medical Center (IL) starts a three-month pilot of Proteus Digital Health’s Discover smart pill sensor, one that is added directly into traditional pills. The sensor detects when the pill has been ingested via a patch worn on the patient’s stomach, and then sends a signal updating an app with medication adherence data.

Humber River Hospital in Toronto works with GE Healthcare to build a 4,500 square-foot digital command center that will aggregate and analyze real-time data from systems across the hospital to help improve staff workflows and patient care.

Privacy and Security

Southwest Community Health Center (CT) notifies patients of a potential data breach resulting from two separate break-ins during which burglars took several computers. No mention is made of whether or not the devices were encrypted. The center is offering affected individuals free identity monitoring and restoration services.

Mississippi’s Medicaid Division alerts 5,220 people of potential PHI exposure stemming from six online forms managed by a third party that were sent to staff via unencrypted emails for nearly three years.

Public school guidance counselor and West Carolina Counseling Services owner Joseph Korzelius admits to using information from his sessions with elementary students to file $450,000 worth of false Medicaid claims. He faces up to 10 years in jail and a $250,000 fine.

Innovation and Research

A team of researchers from MIT and Harvard develop a proof-of-concept tattoo ink that changes color based on metabolism changes in the body, allowing the tattoo to act as a low glucose or dehydration indicator.

Healthcare researchers call out the tendency of journalists to create headlines out of health studies that are “deeply flawed,” citing several articles related to the tenuous (and later debunked) claim that EHRs do in fact lead to improved outcomes. “Health care already consumes almost a fifth of America’s GDP — two or three times every other nations’ costs despite our often inferior outcomes,” they write in their conclusion. “It is vital that all stakeholders — journalists, scientists, policymakers, editors and the public — have a better understanding of basic research design and data interpretation. During this unusual moment in history, when politicians seek out whichever facts suit their ideology, the role of good science — and good reporting — could not be more vital.”

A Black Book survey finds that an overwhelming majority of hospital executives and managers will ultimately look to population health management-focused IT as patient accounting systems as they continue to shift their organizations to value-based care. Allscripts, Cerner, and Epic seem to have the most mindshare of those surveyed.

Government and Politics

President Trump decides to keep Francis Collins, MD on as head of NIH, a position he has held since 2009.

A VA spokesman confirms that Cerner will replace only the agency’s EHR, and that Epic’s $624 million contract to implement an appointment scheduling program for the VA is not in jeopardy.

HHS appoints Bruce Greenstein CTO. Greenstein was most recently president of behavioral health tech company Quartet Health, and served under Louisiana Governor Bobby Jindal as secretary of the Dept. of Health and Hospitals.

Other

The Government of Nova Scotia narrows the field of contenders for a “One Person, One Record Clinical Information System” to Allscripts and Cerner. Based on the procurement listing sent over by HITGeek, it looks like they beat out Evident, Harris Healthcare, and Meditech in preceding rounds that began last December.

In other northern health IT news, the provincial auditor of Saskatchewan recommends the Ministry of Health replace its 50 year-old IT system with one that can better screen the billing activity of physicians that are still paid on a fee-for-service basis. The auditor also recommends the development of standard criteria to more efficiently identify physicians whose billing practices should be investigated.

E-prescribing of controlled substances increased year over year by 256 percent, according to the latest progress report out from Surescripts. Nearly 75 percent of prescriptions in 2016 were electronic, totaling 1.6 billion.

Sponsor Updates

Meditech customers lead lists of five-star and double five-star hospitals.

Liaison Technologies will exhibit at the Cerner North Atlantic Regional User Group June 12-14 in Springfield, MA.

MedData will exhibit at the Ohio Hospital Association Annual Meeting June 12-14 in Columbus.

Contacts

There has been quite a bit of reader feedback about my recent Curbside Consult addressing the ECW settlement. Several readers agreed with my assertion that multiple vendors have gamed the certification process, with one mentioning “extraordinary actions” taken to pass the testing, but that the product was “replaced by corrected code before the production code was released.” Given the way testing occurs, I bet that type of maneuver occurs more often than we’d like. Technically that would be fraud, regardless of how they try to mitigate it. Unfortunately, other vendors haven’t been caught (yet) and/or didn’t allow the products of their deception to go into general release. Hopefully those companies are on notice and will toe the line.

Other readers called for zero tolerance for ECW and other vendors who cheat, including jail time or outright closure of the company. Some felt I was soft on ECW, even “tender.” Let me go on record as saying what they did was despicable – however, I’m a firm believer in the American justice system and we have a couple of things called the law and due process. Whether you think entering into a settlement is tantamount to pleading guilty, there has not been an admission of guilt and no criminal action has been filed that I can find, and trust me, I’ve been looking. My lack of a torch and pitchfork should not be construed as acceptance or approval of what was done. Still, I was surprised by the number of emails I received that attacked me personally or suggested I don’t respect patients. As much as I believe in justice, I also believe in redemption and this is an opportunity for ECW to make things right. As one reader said, “No one benefits if an EHR is litigated into bankruptcy.” Let’s not forget the vendors who have closed their doors abruptly in the past, holding their clients (and the data of tens of thousands of patients) hostage.

Another reader who is in the vendor space mentioned that his employer has already received calls from clients threatening to file whistleblower actions unless specific defects were fixed, regardless of whether they had anything to do with certification or not. Product liability law is a specialized discipline and I don’t think adding potentially hundreds of suits to the environment will result in positive change. Look at how healthcare has dealt with harm in the past: Until you get past the culture of fear and penalty, people are reluctant to report issues or to be part of the solution. Another vendor reader mentioned his company is considering being less transparent with their “known issues” lists because of fear of escalation to frivolous lawsuits. That would be unfortunate as well.

One reader offered an interesting thought around analyzing the percentage of budget that top vendors devote to R&D. There could certainly be some interesting data there and you could come up with some conclusions from annual reports and shareholder documentation. Unfortunately, privately held companies don’t have to disclose anything, so we’d be relying on their report. We’ve heard self-reported statements about this over the last year and many felt they were inaccurate, so it’s not likely that we will get “real” numbers anytime soon. I’d personally like to see the R&D budget compared to support compared to marketing and sales. There are several vendors I work with who spend entirely too much on the latter while shortchanging the former.

Others mentioned my lack of attention to the potential impact on clients. Frankly I think it’s too early to discuss, as we don’t have a full picture of whether those practices will be asked to repay incentive money. Any mandatory repayment would almost certainly create the potential of a class action suit against ECW. That’s precisely why I advised my colleagues on the system to sit tight and see how it unfolds and what remediation is offered and how it actually plays out. They’re in an incredibly vulnerable position right now and it would be easy for another vendor to try to take advantage of their situation. Anyone who predatorily goes after these practices should be ashamed, and I know they’re already out there. The last things these practices need is a hasty move or a poorly considered replacement decision.

Regardless of your position on the guilt or innocence of a vendor and whether the punishment was appropriate, this event has the potential to change the healthcare IT landscape in uncertain ways. I hope that other vendors take the advice of one reader and revisit their compliance programs. Ensuring a culture of honesty, accountability, and understanding of the fact that you hold people’s lives in your hands needs to be at the forefront of thought as corporate decision-making occurs. It’s unfortunately not as common in the US today as we would like, whether in healthcare, the automotive industry, or just about anywhere people are trying to make a profit.

Other readers offered answers to the question of what they’d do with the whistleblower payment, with several noting that legal fees will consume a good portion of it. One mentioned that he would donate to non-profits promoting expansion of EHR systems to practices serving indigent patient populations and that cannot afford to buy them. Or to scholarship funds for computer science students willing to commit to working with those practices to help them implement those systems. Both are great ideas, although I’d like to see vendors contributing to those kinds of initiatives outright, rather than having someone do it as a result of a legal action. Or how about scholarships for patient safety training to ensure caregivers and technology professionals know how to spot these kinds of problems? The reader also noted he’d reserve a few dollars to buy a good bottle of bourbon as a reward for a job well done. Based on the level of documentation and time spent by the whistleblower, I’d suggest more than one bottle would be in the offing.

I don’t think this is the last time we’ll see something like this, and the problem isn’t just on the vendor side. I’ve seen plenty of “creativity” and shortcuts from hospitals and health systems with homegrown systems or with vendors outside the CEHRT space, and although they won’t be caught for fraud during the certification process, they are eventually going to run afoul of patient safety. The question is whether organizations will find the settlement motivational and will clean up their houses voluntarily, or whether more headline-generating actions will need to occur to move the industry where it needs to be. The other possibility is more consolidation in an already shrinking industry, which could have unpredictable effects on innovation and emergence of new vendors. The one thing I can say for sure is that only time will tell.

Rush University Medical Center (IL) pilots Proteus Digital Health’s smart pill sensor, one that is added directly into traditional pills. The sensor detects when the pill has been ingested, and then sends a signal updating an app with medication adherence data.

A team of researchers from MIT and Harvard develop a proof of concept tattoo ink that changes color based on metabolism changes in the body, allowing a tattoo to act as a low glucose or dehydration indicator.

HHS issues a cyber notice alerting healthcare organizations that the WannaCry ransomware attack is causing major operational issues for two large, multi-state hospital systems, and reiterates that the virus continues to pose a threat.

ONC awards a combined total of $35,000 to the three winners of its Privacy Policy Snapshot Challenge, a contest that asked developers to create new Model Privacy Notices generator that helps software vendors create consumer-facing privacy and security policy.

A Health Affairs article discusses the research potential that EHR interoperability and data analytics will have on generating clinical evidence, saying “the ability to harness good quality, usable data from EHRs will likely be as revolutionary for health care as the Internet was to other industries.”

Top News

VA Secretary David Shulkin, MD announces the VA will shut down its VistA EHR and join the DoD in implementing Cerner Millennium, explaining, “The VA’s adoption of the same EHR system as DoD will ultimately result in all patient data residing in one common system and enable seamless care between the Departments without the manual and electronic exchange and reconciliation of data between two separate systems.”

HIStalk readers (who predicted the Cerner decision in a reader survey earlier this year) didn’t waste time weighing in once the news crossed the wire yesterday – nearly a month before Shulkin’s self-imposed decision deadline. VA Worker says, “Here we go again. VA wants to replace VistA with Cerner but will never be able to afford it.” USA First? points out that, for all the Trump Administration’s efforts to keep American jobs on American soil, they’ve chosen a vendor that has sent 3,000 software jobs overseas.

Epic also shared its reaction via a presumably non-marketing rep: “As the largest electronic health record vendor in the United States, covering two-thirds of the nation’s patients, we are proud to serve our veterans both through the VA scheduling project and through our customers that care for millions of veterans across America. These customers are the top health systems in America and we stand with them, committed and eager to ensure veterans get the very best medical care regardless of where they receive it.”

My thoughts are these: Cerner was the only reasonable choice since the DoD had already selected it, but it’s still surprising they went without bidding and named Cerner before negotiation with them began (that’s more of how Epic customers buy software). The company will presumably have more control over naming its price than it did with DoD, where it was a subcontractor under Leidos, and it may be that Cerner gets to keep all the money this time. It’s also to the company’s strong negotiating advantage that both Congress and the President have publicly cheered the VA’s choice of Cerner, making it unlikely that the VA wants to rule out Cerner over price negotiations. The VA has previously suggested that its price tag will be multiples of the DoD’s, perhaps well over $10 billion to $12 billion.

The systems will be theoretically interoperable, but there’s still a lot of work to be done to standardize terminology and functionality to make even the same system talk to another user whose workflows and use cases are different. There’s probably still a lot of consulting work required. It will be interesting to see which firms attempt to feed at the trough of this contract, as well as whether or not the VA and DoD will truly work as a single customer. Will Cerner and the inevitable consultants get stuck trying to broker agreements on major decisions so they don’t end up creating dissimilar systems?

It’s also worth noting that project timelines will need to be synched to avoid temporary interfaces to the legacy systems. Ironically, having the same system may require more VA-DoD cooperation than running separate ones. On the flip side, it’s also important to recognize that the VA and DoD have vastly different needs, and that in the case of the VA (unlike the DoD), its VistA system contains a lot of VA-specific non-clinical functionality, such as management modules for departments that aren’t involved in patient care. VistA is not just an EHR.

Reader Comments

From Mighty Med: “Re: Walnut Hill Medical Center closure. The self-touted hospital of the future abruptly shuts its doors after being open for less than three years. It’s just another example of healthcare disruption gone awry.” The $100 million, 100-bed Dallas hospital did indeed cease operations as of June 1, citing only it’s decision to no longer participate in the Medicare program. A former employee wrote a Facebook farewell message (later taken down) praising his colleagues for working without the “unlimited resources” of traditional hospitals, implying that it was struggling in some way. Officials touted the facility as being designed “completely from the patient’s perspective to create a stress-free atmosphere for healthy recovery.“

From Just Wondering: “Re: John Fleming’s desire for a single unified EHR. Is he as stupid as he sounds?” Hardly. The former Louisiana representative, businessman, and MD has done stints at the Navy Regional Medical Center (CA) and in private practice. He implemented his first EHR in 1997 and went fully paperless two years later. Fleming’s belief that “every American should have a single, unified electronic health record system that resides in the cloud and is under full control of the patient, of the individual, of the American” is the same pipe dream that dozens, if not hundreds, of health IT companies and venture capital firms have been throwing millions of dollars at for years. As the new deputy secretary of health technology reform, he’s becoming privy to the many public- and private-sector interests that will keep that pie-in-the-sky patient record from being developed anytime soon.

HIStalk Announcements and Requests

An anonymous vendor has graciously donated $500 to my project to fund DonorsChoose teacher grant requests in return for mentioning a survey they’re interested in. They’ll also donate a bunch more money if the survey gets at least 100 responses. Providers, please click here and spend a handful of minutes and together we’ll to help a classroom in need. Thanks.

Webinars

June 22 (Thursday) 1:00 ET. “Social Determinants of Health.” Sponsored by Philips Wellcentive. Presenter: David Nash, MD, MBA, dean, Jefferson College of Population Health. One of the nation’s foremost experts on social determinants of health will explain the importance of these factors and how to make the best use of them.

June 29 (Thursday) 2:00 ET. “Be the First to See New Data on Why Patients Switch Healthcare Providers.” Sponsored by Solutionreach. As patients pay more for their care and have access to more data about cost and quality, their expectations for healthcare are changing. And as their expectations change, they are more likely to switch providers to get them met. In this free webinar, we’ll look at this new data on why patients switch and what makes them stay. Be one of the first to see the latest data on why patients leave and what you can do about it.

July 11 (Tuesday) 1:00 ET. “Your Data Migration Questions Answered: Ask the Expert Q&A Panel.” Sponsored by Galen Healthcare Solutions. Presenters: Julia Snapp, manager of professional services, Galen Healthcare Solutions; Tyler Suacci, principal technical consultant, Galen Healthcare Solutions. This webcast will give attendees who are considering or in the process of replacing and/or transitioning EHRs the ability to ask questions of our experts. Our moderators have extensive experience in data migration efforts, having supported over 250+ projects, and migration of 40MM+ patient records and 7K+ providers. They will be available to answer questions surrounding changes in workflows, items to consider when migrating data, knowing what to migrate vs. archive, etc.

Acquisitions, Funding, Business, and Stock

Learning management systems vendor Relias Learning acquires WhiteCloud Analytics for an undisclosed sum. Reliance has been on a bit of a spending spree since March of last year, acquiring six other companies including analytics firm Care Management Technologies.

Aegis Health merges with digital marketing firm Clariture to form Trilliant Health. The companies will retain their brands as separate business units.

Announcements and Implementations

Mayo Clinic (MN) will use 2bPrecise’s clinical genomics solution to add genomic information into its Epic EHR. The organizations will also work together to research and develop genomics-based care protocols, particularly for patients with cardiovascular genetic disease.

Aprima announces record growth for the fiscal year, including revenue, customer retention rate, and the relocation and expansion of its headquarters.

Technology

Apple announces new devices and features at its developers conference – none of which are all that earth-shattering and only some of which are relevant to healthcare. The company will attempt to keep up with the virtual assistant Joneses with the introduction of a Siri-powered HomePod. It has added AI capabilities to its Watch, giving it the ability to serve up motivational fitness messages when steps are down. Users will also be able to link their devices to Dexcom’s glucose sensor via a new API. Perhaps the most potentially life-saving enhancement is the Iphone’s forthcoming “do not disturb while driving” feature, which shuts off all distracting notifications when the phone is connected to your car.

Safety Net Connect releases an enterprise version of its Converge referral and care coordination technology that brings together behavioral and physical health, and social services.

ICare adds order sets and care plans from Zynx Health to its EHR for acute care providers and SNFs.

Government and Politics

ONC announces the winners of its Privacy Policy Snapshot Challenge, the aim of which escapes me as the number of these contests seems to increase in direct correlation to the market-worthy usefulness of their winning ideas.

Sales

Tufts Medical Center (MA) chooses ZappRx to automate the ordering of specialty drugs, expecting to reduce the average prescribing time from 20 minutes to three minutes.

Privacy and Security

HHS alerts providers to the “significant” challenges two unnamed multi-state hospital systems are still experiencing as a result of WannaCry malware, noting that the virus can live on a machine that has been patched, and that its repeated attempts to scan can disrupt Windows operating systems.

Innovation and Research

Early performance data on IBM Watson for Oncology shows that Watson-generated treatment plans for 362 cancer cases were found to be in line with oncologist recommendations in 96 percent of lung, 81 percent of colon, and 93 percent of rectal cancer cases.

People

Michael Caponetto (West Health) joins government healthcare program services company SynerMed as CFO.

Other

The New York Times addresses the “virtual velvet rope” creeping into healthcare – one that is moving beyond celebrities and sheikhs taking over hospital wings and turning the more mundane world of direct primary care into one of ultra high-end concierge practices. Private Medical, for instance, charges between $40,000 and $80,000 per year per family for round-the-clock physician access and near-immediate access to specialists and hospitals across the country. Launched by HealthLoop founder Jordan Shlain, MD in 2002, the company has almost no Web presence, gaining new patients almost exclusively through word of mouth.

Sponsor Updates

Direct Consulting Associates donates fabric and stuffed animal kits to help middle-school students make stuffed animals, blankets, and pillows for local charities.

VA Secretary David Shulkin, MD announces that the VA will shut down its VistA EHR and join the DoD in implementing Cerner Millennium, explaining, “The VA’s adoption of the same EHR system as DoD will ultimately result in all patient data residing in one common system and enable seamless care between the Departments without the manual and electronic exchange and reconciliation of data between two separate systems."

At the 2017 ASCO Annual Meeting, IBM presents performance data on Watson for Oncology. A multidisciplinary tumor board and Watson for Oncology both independently reviewed and generated treatment plan recommendations for 362 cancer cases, after which Watson-generated treatment plans were found to be in line with oncologist recommendations in 96 percent of lung, 81 percent of colon, and 93 percent of rectal cancer cases.

Walnut Hill Medical Center, which billed itself as the “hospital of the future” when it opened in 2014 , closes suddenly. Officials declined to provide details, other than to say that the hospital’s provider agreement with Medicare had expired and it would cease operations after June 1.

Quite a few people called or emailed this week to find out what I thought of the EClinicalWorks settlement. Two of them were ECW users asking for my advice on whether they should change EHRs and, if so, what I thought they should be looking at. For those practices potentially impacted by the alleged wrongdoing, it’s a very uncertain time. My advice was to pause and let the dust settle before making any decisions. Neither of the ECW physicians I talked to this week had concerns about how the system is actually performing based on their scope of use, and felt fairly confident that they’re not experiencing functionality issues that impact patient care.

As for those that reached out simply curious about what I thought, I’ll share what I had to say. There were several allegations addressed in the settlement. I say “allegations” deliberately because ECW hasn’t admitted guilt nor has it been proven in a court of law. Everyone can speculate on the fact that they settled, but given that I have a plaintiff’s attorney in the family, I understand how expensive litigation can be and how $155 million may be a bargain compared to having to mount a defense, deal with the side effects of having half your company (and your customers) deposed, and having ongoing distraction that impacts your ability to keep the lights on and the business running.

First, let’s look at the kickback issue. The suit alleged that it gave kickbacks to customers for promoting its products, including payments for reference site visits. Many of the vendors I’ve worked with would also fall into this category. During my days at Big Hospital System, we regularly received extra attention from our vendor in exchange for being a reference site, and at times we also received credits against our software maintenance payments. I’m sure that could be construed as a kickback, although our site visits were quite “tell it like it is” rather than pure attempts to induce anyone to switch to the vendor. We always insisted that the vendor reps stay out of the discussion and sit in the back of the room or outside the room altogether. It looks like ECW also paid a bonus when prospects actually signed, and paid individual physicians to do references, which is a little murkier.

The way it’s described in the actual filing, any “manufacturers of products paid for in whole or in part by federal healthcare programs may not offer or pay any remuneration, in cash or in kind, directly or indirectly, to induce physicians or hospitals or others to order or recommend products paid for in whole or in part by Federal healthcare programs such as Medicare and Medicaid.” If you take that at face value, then the medical device reps need to stop wooing the cardiologists and orthopedic surgeons, regardless of whether they’re reporting their meals and tchotchkes in compliance with Open Payments. The language also applies to services, so the people from hospice that bring lunch while they explain the services they offer are guilty as well, even though they’re a nonprofit.

Next, let’s look at the issue of cheating on certification. Although some of what they did (such as hard coding the RxNorm codes for the test scripts rather than having the system access the entire library) is pretty egregious, anyone who’s been part of a certification process knows that there’s a gray area between complying with the test scripts and complying with the spirit of the requirement versus the letter of the requirement. There’s plenty of functionality out there that passes the test scripts but isn’t user friendly or sometimes isn’t even usable.

Let’s also look at the allegation that ECW “released software without adequate testing and overly relied on customers to identify bugs and other problems. Some bugs and problems – even some identified as ‘critical’ or ‘urgent’ – persisted on ECW’s bug list for months and even years. ECW lacked reliable version control, so problems addressed in one version of the software or for one particular user could reappear in other versions or remain unaddressed for other customers.” I’m currently working with half a dozen vendors who could fall into that description, and can name a few more to round out the group. Nearly every vendor I’ve worked with is guilty of this to some degree.

As a customer, I’ve been part of beta testing programs that are more like alphas, and have seen code that doesn’t seem to have been tested by anyone conscious. Sure, the coded functionality may have met the technical requirement specifications, so it passed, but when deployed to the field it’s broken or simply useless. I heard from a couple of friends who work for vendors that they were taking joy in ECWs pain. I challenged them to think about their own situations, and whether they’ve ever let a regression error go out the door. It sobered them up pretty quickly. Developers who live in glass houses definitely should not throw stones, because they could be the next ones in the spotlight.

That takes me to looking at the whistleblower component. There was quite a bit of buzz around the fact that the software technician who filed the original suit will receive $30 million. I’m wondering if this is going to be an incentive for individuals to try to prove wrongdoing across the industry in exchange for a potential windfall. Hopefully, this will spur vendors to pay more attention (and devote more resources) to defect resolution as well as defect prevention, since most vendors likely have a backlog of issues needing remediation. On the other hand, it could lead to a lot of rock-turning during which plenty of creepy crawlies will come to light. If vendors have robust systems to manage their issues they’ll persevere, but if not, potential whistleblowers could create a lot of noise that will create distractions that may ultimately harm customers.

Hopefully this settlement will be a call to action for vendors to get their houses in order, and bring greater transparency to the sausage-making that is the certification process. It’s been interesting, though, to see the number of people putting the blame on the certification process itself. The bottom line is that there are rules; if we think they are unfair, we should seek to have them changed in an orderly way rather than just flout them. It will be interesting to look back on this in six months or a year and see whether it’s changed anything or whether it just goes down as another footnote on corporate wrongdoing.

What would you do with a $30 million whistleblower settlement? Email me.

The Health Care Industry Cybersecurity Task Force, per a Cybersecurity Information Sharing Act of 2015 mandate, releases its report to Congress, detailing six high-level directives over the course of 88 pages.

Led by former UnitedHealthcare CEO Bob Sheehy, Minneapolis-based Bright Health closes a $160 million round of financing it will use to expand into new markets via private health insurance exchanges and health system partnerships.

The HHS OIG’s Congressional report highlights challenges related to protecting the privacy and security of the data it collects and maintains, as well as those related to “effectively using data to detect and prevent improper payments and to ensure safety and quality of care for program beneficiaries.”

CHIME has published a far less intimidating 11-page summary of the report’s 100-plus recommendations. HHS officials have thus far been mum on the forthcoming HHS cybersecurity center’s role in fleshing out the recommendations.

Reader Comments

From Jet Blue: “Re: AirStrip Technologies. I met with a prominent venture capital firm today, and we discussed the many high-flying digital health companies that have been funded over the last few years. I learned that AirStrip Technologies has been acquired by Patrick Soon-Shiong, MD. He intends to combine AirStrip with his other companies such as ISirona and Harris CareFx. Apparently the deal is being kept under wraps.” Unverified. ISirona and Harris are among the eight companies NantHealth has acquired over the last six years. AirStrip has flown fairly under the radar this year, and issued just a handful of press releases in 2016. I interviewed President Matt Patterson, MD last March.

From HIT Apostle: “Re: Integration. We are exploring different options for how to best integrate EHR data into our analytics product suite. This would include becoming HIPAA compliant, hiring an ETL team, and adding data processes to our operating model. Have you ever asked your readers what a ballpark figure cost is for this? Are there more cost efficient options, like working with an integration vendor, such as Redox?” I don’t believe I have, so I’ll invite readers to comment with advice and experiences.

HIStalk Announcements and Requests

A HIStalk sponsor and Donors Choose supporter asked me to share this survey on EHR services. They plan to double their already sizable donation once they reach 100 responses.

It’s almost an even split when it comes to the benefits readers believe CommonWell brings to patients, a stat that MC calls into question: “Something very funny happened with this poll. When there were about 80 to 100 responses it was OVERWHELMINGLY leaning towards LESS THAN EXPECTED. Now it is 244 to 252?” April isn’t crazy about how the poll was worded: “Voting ‘less than expected’ (regardless of whether your expectations were very high) leaves the poll results looking like CW isn’t doing anything to benefit patients. ‘More than expected’ indicates you didn’t expect it to do much to begin with. I like the fact that CW is showing steady progress in addressing some of the hardest issues in interoperability. I also like the fact that they opened up the ability for patients to initiate their own record search earlier this year.”

New poll to your right or here: Would you consider switching EHRs if your vendor was involved in a legal situation similar to that of EClinicalWorks? Feel free to add write-in commentary regarding what vendor(s) you would put at the top of your shopping list and how much weight certification would carry.

This Week in Health IT History

One year ago:

Rumors surface – again – that McKesson is considering selling or merging its McKesson Technology Solutions business unit in the face of drug pricing pressures.

Walgreens licenses kiosk and EMR software from Ethidium Health Systems for use in its Take Care Health Systems retail clinics.

Duke Clinical Research Institute concludes that extra pay does not improve hospital performance.

Weekly Anonymous Reader Question

Last week’s results were slim, indicating that either I asked for too much or that readers don’t have much experience with mentor/mentee relationships (which I doubt given the interest in our webinar on that very topic several weeks ago). Here are the responses I received:

I work in a company full of people who are almost all fantastic at their jobs. I try to identify the strongest skills in the people I work with most often, and then I emulate them when in relevant situations. As my assignments change, the people and skills I’m exposed to change, so I continue to develop further.

They listen when I have a complaint – about life or work, they listen. Occasionally some wisdom comes back, but they mostly know just to listen and let me be heard.

This week’s survey: Would you recommend to a relative or colleague that they switch careers to health IT? Why or why not?

Last Week’s Most Interesting News

Ascension-owned Seton Healthcare (TX) goes back to paper after detecting suspicious activity on its network.

21st Century Oncology (FL) files chapter 11 bankruptcy.

The VA’s IT budget is reduced as it grapples with the decision to either modernize VistA or implement a commercial EHR.

Webinars

June 22 (Thursday) 1:00 ET. “Social Determinants of Health.” Sponsored by Philips Wellcentive. Presenter: David Nash, MD, MBA, dean, Jefferson College of Population Health. One of the nation’s foremost experts on social determinants of health will explain the importance of these factors and how to make the best use of them.

June 29 (Thursday) 2:00 ET. “Be the First to See New Data on Why Patients Switch Healthcare Providers.” Sponsored by Solutionreach. As patients pay more for their care and have access to more data about cost and quality, their expectations for healthcare are changing. And as their expectations change, they are more likely to switch providers to get them met. In this free webinar, we’ll look at this new data on why patients switch and what makes them stay. Be one of the first to see the latest data on why patients leave and what you can do about it.

July 11 (Tuesday) 1:00 ET. “Your Data Migration Questions Answered: Ask the Expert Q&A Panel.” Sponsored by Galen Healthcare Solutions. Presenters: Julia Snapp, manager of professional services, Galen Healthcare Solutions; Tyler Suacci, principal technical consultant, Galen Healthcare Solutions. This webcast will give attendees who are considering or in the process of replacing and/or transitioning EHRs the ability to ask questions of our experts. Our moderators have extensive experience in data migration efforts, having supported over 250+ projects, and migration of 40MM+ patient records and 7K+ providers. They will be available to answer questions surrounding changes in workflows, items to consider when migrating data, knowing what to migrate vs. archive, etc.

People

Acquisitions, Funding, Business, and Stock

Health insurance startup Bright Health raises $160 million in a Series B round led by Greenspring Associates. Co-founded by former UnitedHealthcare CEO Bob Sheehy, the Minneapolis-based company works with health systems looking to package insurance plans with their clinical services.

Decisions

The University Of South Alabama Health System (AL) plans To switch from Siemens Soarian to a new Cerner EHR.

Buchanan County Health Center (IA) switched from Meditech to Epic in March.

Platte Valley Medical Center (CO) will switch from Siemens Soarian to Epic on May 30.

These provider-reported updates are supplied by Definitive Healthcare, which offers a free trial of its powerful intelligence on hospitals, physicians, and healthcare providers.

Announcements and Implementations

Reaction Data publishes a new report on the UK imaging market. Carestream, Sectra, and Agfa Healthcare have the best foothold on enterprise business across the pond.

Hackensack Meridian Health (NJ) will add Cota Healthcare’s precision medicine technology to its five-month pilot of IBM Watson as a clinical decision support tool for oncologists. The trial will involve 10 physicians and up to 500 patients.

Sales

Memorial Hospital (IL) will convert from Meditech to Cerner early next year.

Lewis County General Hospital (NY) considers upgrading to Meditech 6.1. Director of Information Systems Robert Uttendorfsky anticipates that transition will cost at least $1.5 million and take 18 months.

St. Luke’s Health System (ID) will deploy Voalte’s communications technology across its eight hospitals.

The Queen’s Health Systems (HI) will integrate Recondo Technology’s ClaimStatusPlus with Epic. The organization got its start in 1859, when Queen Emma and King Kamehameha IV went on a door-knocking tour to raise funds for what would become The Queen’s Medical Center. It is the first (and perhaps only) health system in the US to be founded by royalty.

Government and Politics

HHS Inspector General Daniel Levinson releases OIG’s semi-annual report to Congress, highlighting challenges related to protecting the privacy and security of the data it collects and maintains, as well as “effectively using data to detect and prevent improper payments and to ensure safety and quality of care for program beneficiaries.”

Privacy and Security

Appthority dubs a new backend data exposure risk HospitalGown, outlining in the cheekily titled report above the havoc it could wreak in enterprise environments.

Identity management system company OneLogin experiences a data breach, putting the information of the Stanford School of Medicine (one of its biggest customers) at risk.

An unspecified IT issue at The Cosmetic Institute in Australia causes a private index of patient data – including pre- and post-surgery photos, Medicare numbers, and other intimate patient details – to become publicly accessible via the surgery’s website.

Innovation and Research

MIT Technology Review reports on 23andMe’s decision earlier this month to ask its customers for help in conducting research on pain tolerance. The consumer-friendly genetics company aims to enroll 20,000 people to take surveys on pain tolerance and pain history; 10,000 of those will conduct at-home cold pressor tests, where subjects stick their hand in ice for up to three minutes. The data will likely be used to inform studies on personalized pain medication.

Other

Doctors of BC President Alan Ruddiman, MD cites a “broken culture” at Island Health and its Nanaimo Regional General Hospital as one of the main reasons for continued physician dissatisfaction with the Vancouver health authority’s $135 million Cerner implementation. According to Ruddiman, such discontent has led to physician burnout and resignations – a state of affairs that will not only affect patient care, but the community, too. “If the medical personnel are hurting and they are uncoupling from this hospital then it’s only a matter of time where this gets known as a community that’s not an attractive place to live and work and that hurts everybody …” he added.

The local paper casts Judy Faulkner-like aspirations onto VitusVet founder Mark Olcott, an entrepreneurial veterinarian working to make pet health records interoperable, and appointments and prescriptions easier to fill. Focusing on practices with four or more vets, the company hopes to pass the $1 million revenue mark this year after grossing a quarter of that in 2016.

Sponsor Updates

LogicWorks develops a new set of DevOps tools for running applications on the AWS cloud.

The Australian Digital Health Agency releases a request for tender seeking technology vendors that will help it achieve “a digitally interoperable environment for the Australian health and care system,” over the next five to 10 years.

Accenture acquires LabAnswer, a laboratory research and informatics technology consulting firm, and will combine the business with its existing R&D informatics capabilities to establish the Accenture Scientific Informatics Services division.

Forbes also estimates that the company’s annual revenue is $200 million and it’s growing 100 percent per year, with most of the money coming from drug companies anxious to get their message in front of patients at an opportune time.

Vivek Kundra, the first US CIO, is a company EVP.

HIStalk Announcements and Requests

Tuesday’s HIStalk page views exceeded 10,000, which isn’t a record or even all that much higher than the usual daily traffic, but it’s the highest count during a non-HIMSS week other than June 28, 2016 (when McKesson announced that it would divest its Technology Solutions business) and July 30, 2015 (when the DoD awarded Leidos/Cerner its EHR contract).

I thought it would be interesting to look at the percentage of females serving on the executive teams of the top five healthcare IT companies by revenue as listed on the new Healthcare Informatics 100, which might bring to mind the old Doors song “Five to One”:

The settlement could be only the beginning of ECW’s problems, as it now has to deal with potential customer defections, the inevitable drop-off in sales, and potential class action provider lawsuits. It could possibly be sued by its certifying body, Drummond Group, plus it is required by the settlement terms to implement internal and external review programs.

I assume the value of the settlement was based on the MU payments that were made to ECW-using EPs, which I’ll also assume means that HHS won’t go after the EPs individually. The complaint says the federal government is entitled to recover triple the value of fraudulent claims (presumably the MU incentives paid) plus a percentage of the company’s profits that represented “undue enrichment.” Still, as reader Debtor points out, ECW-using EPs could have been paid around $2 billion in Meaningful Use incentives, so as he or she says, “that the DOJ settling for pennies on the dollar and no criminal prosecution is unbelievable.”

Does Drummond Group, which certified ECW’s EHR, bear any responsibility (legal or otherwise) for failing to detect that ECW was – according to the complaint – rigging its test results? On the other hand, it could argued that since the certification testing scenarios are public and static, the certification body has no easy way to detect fraud in observing only the desired scenario outputs. Certification testing is not dynamic nor comprehensive – it’s following a script to see if the expected outputs are produced.

The $30 million whistleblower payment will surely encourage others to report any similar problems with other vendors.

Clearly DOJ was not happy that ECW apparently charged customers for software updates, made it hard and/or expensive for them to migrate from ECW to other EHRs, and did not make it easy for its customers to exchange information with other practices.

The kickback portion of the complaint arose from ECW giving users a $500 maintenance credit to refer a prospect who eventually signed on as a customer (those payments totaled $144,000), paying users to host site visits ($249,000), compensating customers to provide good product references, and providing consulting fees, honoraria, and gifts to influential users who pitched its product, with one unnamed doctor earning “tens of thousands of dollars in ‘consulting’ fees.” The complaint makes it clear that manufacturers can’t pay any kind of remuneration to encourage use of their products for which the federal government pays via Medicare and Medicaid.

It’s not clear how the settlement affects ECW-using EPs who could continue attesting under the Medicaid part of Meaningful Use for several more years. Apparently not at all since the product’s certification remains intact.

Two ECW technical employees will pay relatively small settlement amounts over the product’s inability to process RxNorm terminology for e-prescribing. One of those employees was the developer in charge of the RxNorm software functionality and the other submitted ECW’s final certification application. The complaint says the certification body certified the product in 2013, heard afterward from ECW employees that the software didn’t really process RxNorm codes, and then re-tested the product with the same protocol in 2015, which ECW passed only because it hard-coded the expected 16 RxNorm codes.

The complaint says ECW’s EHR did not use LOINC or SNOMED CT terminology.

The complaint says ECW released software without adequate testing, relied on customers to report problems, allowed critical problems to remain unresolved for months or years, and reintroduced previously fixed bugs because its software version control was not reliable.

The company’s October 6-9 user group meeting should be interesting.

The whistleblower in the case was Brendan Delaney, who was a New York City employee implementing ECW at Rikers Island for prisoner healthcare when he noticed software problems. He has also worked on ECW projects for Arcadia Solutions, HSM Consulting, and as a self-employed contractor. His LinkedIn says he’s revenue cycle manager at NYU Langone Medical Center, or at least was before he learned he’ll be pocketing $30 million (but unfortunately for him, whistleblower windfalls are taxed as ordinary income).

ECW is required to implement a quality assurance program to oversee software defects, usability problems, and any other issues that affect patient safety or product certification and to post known software problems on its portal.

The company is required to create usability and patient safety advisory teams, consisting of at least a doctor, pharmacist, and nurse.

ECW is prohibited from using contract language that prohibits customers from disclosing patient safety concerns and agrees that it won’t enforce that requirement in existing contracts.

The company must help customers who want to migrate to other EHRs and can’t charge them any fees, penalties, or service charges.

ECW is required to contact every customer with an email subject line of “Important information about your EHR software and services. You have new options free of charge to you.” The communication must start with a statement indicating that ECW has settled with HHS OIG to offer them free upgrades to the latest production version.

The company must track any payments made to existing customers for marketing purposes and must list all of payments it makes to providers on its website.

What other vendors should do based on the settlement:

Review the certification process to make sure nothing is being faked, talking to the technical people rather than managers anxious to avoid becoming the shot messenger.

Don’t provide any kind of incentives for customers or their employees to help make new sales.

Make sure customers are notified quickly of software problems that endanger patients or that can cause billing mistakes or certification shortcomings.

Meanwhile, the law firm that represented the whistleblower in the lawsuit adds a few points:

The firm filed Brandon Delaney’s lawsuit against ECW in 2015.

The firm’s website includes archived copies of advisories ECW sent to its customers that warned of software problems.

Brandon Delaney provided this statement: “I was profoundly saddened and disappointed by the indifference of senior health department officials and investigators for New York City when I provided detailed information about serious flaws in the EHR software that could endanger patients. I am grateful that Phillips & Cohen and federal government attorneys recognized the seriousness of my charges and dug into the matter quickly and thoroughly.”

The Letter EClinicalWorks Sent to its Customers Thursday

Dear Customer:

Yesterday we announced a settlement with the government. As part of the settlement, eClinicalWorks paid $155 million and agreed to bolster its compliance program. The inquiry leading to the settlement primarily centered on technical aspects of the Meaningful Use program and allegations that eClinicalWorks software had technical non-conformities related to some of the criteria, all of which have since been addressed.

eClinicalWorks cooperated fully with the government. We have not admitted any fault or wrongdoing, and our goal as a company is to always make sure we are doing the right thing. We have decided to put this matter behind us and concentrate all of our efforts on our customers and continued innovations to enhance patient care delivery. Importantly, our software remains fully certified under the Meaningful Use program.

One of the technical non-conformities alleged by the government involved the use of RxNorm codes in electronic prescriptions. From 2014 to August 2016, electronic prescriptions sent by eClinicalWorks users included NDC codes rather than RxNorm codes. During this time period, more than 500 million prescriptions were successfully transmitted and filled, and most major pharmacies did not support RxNorm codes. The failure to include RxNorm codes in electronic prescriptions was completely inadvertent on the part of eClinicalWorks, as our software used RxNorm codes in other parts of the system, such as in C-CDAs. We gained nothing by not including the codes, which are available for free from the National Library of Medicine. We resolved this issue as soon as we learned of it.

Another technical non-conformity identified by the government involved data portability. The 2014 Edition certification criteria require EHR software to “batch export” patient records. There was confusion about the meaning of this requirement, however, prompting ONC in 2015 to issue a clarifying FAQ. When eClinicalWorks was tested for certification in 2013, its authorized certification body (ACB) at the time, CCHIT, determined that our software satisfied this requirement. In 2015, our new ACB, Drummond Group, disagreed and identified this as a non-conformity. eClinicalWorks resolved the non-conformity in 2015, and our software meets all MU Stage 2 data portability requirements.

Historically, technical non-conformities with the MU Program were addressed through an administrative rather than a legal process (visit the ONC’s Certified Health IT Product List (CHPL) website for a list of EHR vendors with non-conformities: https://chpl.healthit.gov/#/search). eClinicalWorks chose to settle this matter to avoid the uncertainty of a prolonged legal dispute which could have been disruptive to our customers, our employees and our company.

The government also alleged that eClinicalWorks’ customer referral program violated the federal Anti-Kickback statute. Under this program, called “Refer a Friend.”eClinicalWorks granted a credit, typically in the amount of $500, against existing users’ support and maintenance fees. Between 2011 and 2016, eClinicalWorks paid $392,000 to users under this and related programs. While referral programs like this are common in the industry, and while HHS-OIG has provided no guidance regarding them, the government took the position that the payments were improper. We disagreed but have nevertheless discontinued the program.

There is a silver lining to this settlement. Today, eClinicalWorks has a more robust compliance program, and we continue to invest our resources and energy into making sure the products and services we deliver serve our customers well in the long run. We paid the settlement amount using cash on hand and have the resources to continue to grow and innovate.

It is our privilege to serve you. I am committed to enhancing our products and services. We will be releasing V11 later this year as planned and seeking certification for Meaningful Use Stage 3.

We founded this company 17 years ago with the mission of improving healthcare together. The settlement does not change that.

Sincerely,

Girish Navani, CEO

Webinars

June 22 (Thursday) 1:00 ET. “Social Determinants of Health.” Sponsored by Philips Wellcentive. Presenter: David Nash, MD, MBA, dean, Jefferson College of Population Health. One of the nation’s foremost experts on social determinants of health will explain the importance of these factors and how to make the best use of them.

June 29 (Thursday) 2:00 ET. “Be the First to See New Data on Why Patients Switch Healthcare Providers.” Sponsored by Solutionreach. As patients pay more for their care and have access to more data about cost and quality, their expectations for healthcare are changing. And as their expectations change, they are more likely to switch providers to get them met. In this free webinar, we’ll look at this new data on why patients switch and what makes them stay. Be one of the first to see the latest data on why patients leave and what you can do about it.

July 11 (Tuesday) 1:00 ET. “Your Data Migration Questions Answered: Ask the Expert Q&A Panel.” Sponsored by Galen Healthcare Solutions. Presenters: Julia Snapp, manager of professional services, Galen Healthcare Solutions; Tyler Suacci, principal technical consultant, Galen Healthcare Solutions. This webcast will give attendees who are considering or in the process of replacing and/or transitioning EHRs the ability to ask questions of our experts. Our moderators have extensive experience in data migration efforts, having supported over 250+ projects, and migration of 40MM+ patient records and 7K+ providers. They will be available to answer questions surrounding changes in workflows, items to consider when migrating data, knowing what to migrate vs. archive, etc.

Acquisitions, Funding, Business, and Stock

Medical image viewing system vendor TeraRecon acquires machine learning vendor McCoy Medical Technologies and creates a new company that will distribute trained machine learning algorithms for clinical decision support, also offering researchers and hospitals an easy way to distribute their algorithms for research or commercialization.

Accenture will acquire 250-employee laboratory informatics consulting firm LabAnswer, which it will fold into the newly created Accenture Scientific Informatics Services.

Privacy and Security

The medical records (including photos) of 15,000 patients of a Los Angeles plastic surgery clinic – some of them celebrities – have been stolen by a fired employee.

In India, the Mumbai health department’s online birth and death registry is taken offline following complaints that its lack of security was allowing anyone to look up random names and print their birth or death certificates. A government official complains that only the medical health officer is now allowed to use the system and “he cannot keep printing certificates for everyone” in keeping up with the city’s daily workload of 400 births and 200 deaths.

Australia’s health department decides that the records of people who opt out of its My Health Record system won’t be deleted, but rather hidden from providers, allowing those who opt out to change their minds later.

Other

Australia’s Digital Health Agency issues a request for tender for developing a plan to connect all health-related systems over 5-10 years.

A five-sentence letter published in NEJM in 1980 concluding – without much evidence – that opiates aren’t addicting when prescribed for chronic pain has been cited more than 600 times since, with references to the article spiking after OxyContin was brought to market in 1995. The authors note that most of the citations misinterpreted the information or mischaracterized the letter’s conclusions in encouraging doctors to use long-term opiate therapy that contributed heavily to today’s national addiction, leading to their recommendation that authors cite previous studies carefully.

Facebook is hosting an invitation-only meeting next week to court drug companies as advertisers.

I’m the CEO of Definitive Healthcare. We started about six years ago. We provide detailed information and analytics on the healthcare provider market. We track data on everything from hospitals to physicians to imaging centers. Our goal is to have the best data on every facility and provider of healthcare in the US.

Does your business overlap with that of HIMSS Analytics?

HIMSS tracks a lot of data on technologies within hospitals. We do that as well. We’re much more broad. We tie the technology back to the analytics on what’s actually happening at the hospital. Things around readmission rates are very important to our clients. We track a lot of data on affiliations and how these organizations refer patients back and forth across the continuum of care.

How much of the information that you collect in having conversations with people in health systems hasn’t been publicly announced?

A lot of the really interesting stuff that we get is through conversations with IT directors and CIOs at hospitals, as well as people on the finance side. Probably 30 percent to 40 percent of our data is from a completely proprietary source that has not been announced anywhere else.

I assume a significant part of your market is vendors looking for marketing and sales data. What kind of information do they want?

The uses are changing over time. Six years ago, it was, do they have an EHR system? Which one? That is still a very important element of what they want to know, but it’s for a different reason. Oftentimes they’re trying to think about how to bolt on technology.

As the technology is becoming more sophisticated and EHR systems are becoming more ingrained with what they’re doing every day, a lot of our clients are interested in what the healthcare ecosystem looks like in a particular market. Who are the players, who owns who, who works with who and aligns with who. All of that is incredibly important to the technology players because the EHR system being at one hospital is interesting, but where it becomes really useful to healthcare is when everybody can talk to each other.

A lot of the vendors now are thinking about, how do I expand my reach beyond the hospital or the health system to link in all of the imaging centers and the most important physician groups and all of that? Our data helps paint a picture of what that ecosystem looks like and where the informal partnerships and alliances exist. That helps them think about, what is our go-to-market strategy? Who are the important players to get involved that are the influencers and can drive change within that market?

Other things they’ll think about is, depending on what their technology is, the revenue cycle guys will try to understand not only what’s in there today, but the collection process for that hospital and who the important people are for that collection process. The care coordination people want to understand the ACOs that are in partnership with the hospitals. All of that arms them with the information that they need to go have an intelligent conversation with a CIO or a CFO.

Does your conversation touch on user satisfaction with a given product or a potential system replacement?

We don’t go so far as to say somebody is unhappy. There’s some inferred satisfaction with the fact that they’re making a change or looking for a new technology, which is the type of things that our data will pick up. A lot of the people that we’re speaking to on a day-to-day basis are not going to go out on a limb and say, we’re flat-out unhappy with a vendor. Therefore, we don’t necessarily ask that question.

A lot of the product decisions must be driven by new affiliations, where a hospital or practice didn’t necessarily acquire or become acquired, but partnered with another organization in a non-ownership model.

There’s so much of that. Obviously mergers and acquisitions is a pretty tremendous trend within the market right now. We track something like one merger-related piece of news per day, a major piece of news.

Informal alliances are becoming increasingly important because there’s a limit to how far you can take the M&A game, especially as these markets become a bit more concentrated with ownership already. As everything moves to outpatient, it’s a lot less expensive to start this stuff up on your own.

Urgent care is a great example. You can have a couple of physicians who band together and create an urgent care clinic or two or three or four that can become extremely profitable very quickly. The hospitals may end up buying those up over time, but those are sprouting up so quickly that you need to create alliances with those organizations, even if you’re not in a direct ownership situation. The move to outpatient is spreading out the care so much that the need to have these informal alliances is becoming more and more important.

What other big trends are you seeing?

Something that comes up a lot that is nascent but that our clients are particularly interested in is the move towards mobile and telehealth. It’s almost like the Internet was in 2000. Telehealth is finally starting to come to its time in the spotlight. Telehealth has been around for a while and mobile health’s been around for a while, but the tools didn’t exist for it to get exciting — better phones, better cameras, and the ability of wearables that can collect information. All of a sudden all of these technologies can actually work, whereas with the Internet in 2000, it was Pets.com and in 2002, that company went out of business and everybody said, “That was the stupidest idea ever.” Now there’s Chewy, which is a billion-dollar company selling pet food online.

The mobile and telehealth stuff is finding its way now after trying to for many years. We’ve seen a lot of interest and a lot of questions around, what are people doing? What’s working? What’s not? A lot of that is just because it is still such a new market that there’s a lot of interest in how to make it work.

Are health systems forming relationships with turnkey companies like Teladoc that has their own doctors or are they more interesting in creating a service that features their own medical staff and brand identity?

Where we’re seeing health systems attacking is much more around chronic diseases. How do you manage that better? If you think about a capitated payment model where the health systems are taking some of the risk for things like diabetes care, if you can keep people out of the hospitals, obviously that’s a tremendous benefit to you. Things around wearables that can measure blood glucose and technologies like that are very interesting to them, to be able to get that data in real time and essentially get in front of any issues before they become a big issue.

Along the same lines is medication adherence. That’s a little bit out of pure telehealth and more into apps. How do you engage that patient on a regular basis and ensure that they are taking their medications? Once you release somebody from your hospital, how do you make sure that they don’t come back in for the same reason? Payment structures are driving them to think about things like that.

The classic telehealth, the doctor on the phone, is still struggling. Where we’ve seen a lot of success is around more behavioral, psychology, and psychiatry.

Are you detecting budgetary caution around the possibility that many patients could become uninsured with Affordable Care Act changes?

There’s a lot of talk of it. We haven’t completely seen that come through. We haven’t really noticed our clients saying that budgets are getting cut or projects need to be pushed down the line. It is potentially coming. There’s just still so much unknown that nobody’s hit the panic button quite yet.

And, the need for change is so high within the healthcare system that there’s no stopping it. They need to drive down structural costs still applies, whether there’s uninsured or not. On the one hand, you don’t want to spend as much money. On the other hand, you need to change your system quickly enough to be able to deal with lower payments if that’s what’s going to happen in the future.

What’s it like running a research-based business?

The most important thing that we think about is innovation. It’s absolutely essential. How do you get information that nobody else has been able to find, do it in an efficient way, and present it in a way that people can take tomorrow and go utilize? Within healthcare specifically, there’s just so much data that’s out there that it can quickly become noise if you’re not innovating and showing clients, here’s what you should draw from the information. Here’s how you can go use it tomorrow. Here’s data that you just can’t find anywhere else.

It’s an extremely difficult business. It’s competitive. The way to stay in front of the competition is to continue to innovate and do things nobody else is doing. It changes so fast. Every day we’re rethinking about, how do we do this better? That’s essential to staying at the place that we’ve been able to get to.

I took a break from writing over the Memorial Day weekend due to having the privilege of participating in events honoring our nation’s veterans. On Saturday, I assisted with an Honor Flight, welcoming 22 veterans and their families back from a trip to Washington, DC, where they visited the monuments dedicated to their service.

Along with active duty service members, we lined the airport terminal to salute the veterans as they were transported from the gate to the baggage claim area. There they emerged from a tunnel of American flags to greet family and well-wishers in a celebration complete with a USO-style band. These gentlemen, most of whom are in their late 80s and early 90s, helped save the world. I am honored to have been able to work with them.

Three brothers were on the flight, having served in WWII, Korea, and Vietnam. They lifted a beer at the Vietnam Memorial to honor fallen friends. The picture of that moment shares more than a thousand words. WWII veterans are passing on at a rate of 640 per day, according to VA data. Most of the veterans I’ve worked with over the years don’t want to talk about their service, but saying thank you is always appreciated.

Sunday was a little more sobering when I volunteered with a group charged with placing flags at all graves in our National Cemetery as well as on the graves of veterans buried at a dozen Jewish cemeteries. Our local post of the Jewish War Veterans of the USA provided breakfast for over 500 of us before we set out on our task. After the flag is placed, it is saluted. Each veteran’s name is read and they are thanked for their service.

Our small group placed over 1,000 of the 200,000 flags that went out that day. A small commitment compared to what those we honored have given. If you’ve never done this and have the opportunity, I would strongly encourage you to take part. Every one of those flags has a story and it’s something to think about on days when we’re tempted to complain about spotty cell service and slow lines at Starbucks.

I saw patients on Memorial Day itself since many of my partners are former military officers and having the rest of us work allowed them to participate in local remembrances. It was a busy shift due to the three-day weekend.

I experienced something I haven’t seen before, which was having a parent drop off a 12-year-old at the urgent care and then leave him in the exam room to run errands. Of course, we can’t treat a child without a parent there to provide consent, so we had to wait. After an hour, I was wondering at what point it becomes child abandonment when the parent returned, acting like his actions were no big deal. I hope the patient wasn’t too scared about being left alone. We tried to check on him regularly while waiting for Dad to turn back up.

Tuesday sent me fully back into the healthcare IT fray, mopping up after a client who decided to try to install an upgrade over the weekend despite their vendor’s support desk being closed for the holiday. While I was re-running and monitoring the upgrade scripts, I had a chance to catch up on some articles that friends and readers had sent my way.

One caught my attention with its headline that “Patients Fare Worse with Older Doctors, Study Finds.” It cites research from Harvard Medical School looking at Medicare data for over 700,000 hospital admissions. The patient mortality rate rose for each decade of physician longevity, ranging from 10.8 percent for physicians under age 40 to above 12 percent for physicians over age 60. However, physicians who saw large volumes of patients didn’t seem to have a change in mortality rates due to age, rather those rates remained consistent for higher-volume physicians. Seeing more patients may force physicians to stay current, but it could also be that lower volume physicians see fewer patients because they are less knowledgeable.

The article offers some other interesting conclusions, but I’d be interested to hear what readers think. One 74-year-old physician keeps current by reading multiple medical journals each day. That kind of volume would be hard for me to do, so I applaud him for being what he describes as “addicted to keeping up to date.” He’s a medical school dean, so I’m not surprised.

Another piece from Boston’s NPR new station chronicled one burnt-out doctor’s decision to leave medicine. The author notes that while many people ask why she left, virtually no physicians ask her that question. They instead ask how the transition worked.

I’ve had numerous physicians approach me over the last few years asking about clinical informatics as a potential way to get out of clinical practice but still be able to positively impact patient care. I would be dishonest if I didn’t acknowledge that I leveraged the move to full-time informatics as a way to get out of paying for supplemental liability insurance (so-called “tail coverage”) as well as a way to get free of a restrictive non-compete clause. In my situation, those were beneficial side-effects of the move, however, rather than incentives.

The article was sent to me by a former residency colleague who is trying to formulate her own exit strategy. She was one year behind me in training and we caught up recently for drinks. Out of the 13 family medicine residents in our two classes who we’ve kept up with:

Clinical informatics: 1

Residency faculty: 1

Retrained in another specialty: 1

Cosmetic/age-reversing medicine: 2

ER/urgent care: 2

Concierge practice: 1

Left medicine to care for family: 1

Part-time practice: 1

Incarcerated: 1

Full-time primary care: 2

Those are some sobering statistics for physicians who aren’t even 20 years out of training. They also paint a different picture of the primary care shortage, one where lack of training slots are not the problem.

I hate to see my friend consider leaving medicine, as she practices in a relatively underserved area and also serves as the medical director for a home hospice organization. Those vital services aren’t easily replaced. She has already stopped delivering inpatient care and next week marks the end of her hospice practice. Her eight-year plan gets her children nearly through college while letting her only sit for Board recertification exams one more time. I’m glad that she’s designing a strategy that lets her keep seeing patients while trying to address potential burnout. I will be supportive no matter which way she decides to go.

A Brookings Institute report, co-authored with researchers from SUNY Buffalo and the University of Connecticut, finds that the implementation of a health information exchanges in western New York was associated with a decrease in the number of repeated therapeutic procedures performed, but had no impact on the number of diagnostic procedures performed.

EClinicalWorks will pay $155 million to settle a federal False Claims lawsuit alleging that ECW misrepresented its EHR product and paid customers kickbacks for promoting it, the Department of Justice announced today.

The government claims that ECW fraudulently obtained certification for its EHR by hard coding some of the testing elements as provided to its certifying entity. It also says ECW’s software did not accurately maintain a user audit log, did not reliably record diagnostic imaging orders, failed to perform drug interaction checks, and failed to meet interoperability requirements, thus causing false claims for HITECH incentive payments to be paid by HHS.

The company and three of its founders will pay the $155 million settlement.

ECW also entered into a five-year HHS OIG Corporate Integrity Agreement that requires the company to have its software quality control systems externally audited and reported to HHS OIG. The company also agreed to provide prompt notice to customers of any EHR-related safety issues, to make software updates available at no cost, and to assist customers in migrating to other EHRs without charging them. ECW is also required to hire an Independent Review Organization to certify that the company’s agreements with providers comply with anti-kickback laws.

The whistleblower lawsuit was filed by Brendan Delaney, a software technician with New York City Division of Health Care Access and Improvement, who will receive $30 million of the settlement.

I’ve run several reader-provided rumors about the Department of Justice investigation, going all the way back to late 2015.

Digital health updates are written by LoneArranger, an anonymous industry insider.

Digital health capabilities are increasingly becoming more integrated with core healthcare platforms and provider workflows, leading to major changes in the way healthcare is being delivered. There have been several recent developments in the application of technologies such as artificial intelligence, virtual and augmented reality, and wearable devices that have been disruptive, have the potential to change the practice of medicine and transform population health management and precision medicine.

Innovations in areas such as mobile apps, the Internet of Things (IoT), machine learning, and artificial intelligence are being incorporated directly into healthcare applications. As the digital health industry moves into the next wave of innovation, the following areas are those that many healthcare providers, payers, vendors, and digital health startups are targeting for development.

Artificial Intelligence (AI)

AI capabilities will become increasingly accepted and used by healthcare professionals as a clinical decision support tool to identify potential risks, mitigate errors, recognize patterns, and improve disease diagnosis and treatment. AI and Machine Learning will increasingly drive population health analytics, clinical decision support, and scientific research.

Blockchain

This technology framework has the potential to allow hospitals, doctors, and insurance companies to share data more securely, assuming the role of a trusted gatekeeper. Using the concept of a shared ledger, it makes it possible to share information selectively with others. Digital records can be stored with variable access controls and digital assets can be exchanged with minimal friction. Organizations are expressing increased interest in the significant potential blockchain has for improving healthcare information management.

Genomics

A substantial amount of funding has gone into the study of genes as researchers and providers pursue new disease treatment options and patients seek more tailored and personalized healthcare plans. Pharmaceutical companies are leveraging genomics research to develop new medications for cancer and other serious conditions as well as other therapeutic compounds for advanced immunotherapy treatments. Many EMRs are now configured to maintain genomic data in the patient record, along with existing medical data, to provide a more complete picture for providers.

Internet of Things(IoT)

The use of data from portable devices and sensors has given providers more real-time information on patient health status and patients the ability to have tailor-made strategies to combat illnesses and to take a more proactive role in managing their health. The connectivity of healthcare solutions and devices improves patient management, disease management, and the outcome of treatments. Since patients and providers both benefit from IoT, it will have a bigger presence and impact within the healthcare sector over time.

Mobile Apps

The major shift in this area is the evolution from standalone applications to ones that are more tightly integrated with legacy healthcare platforms and the clinicians who use them. Apps that connect providers and patients are gaining traction. These are being used to help coordinate and manage patient care, increase patient engagement, and support more effective treatment of chronic disease conditions.

Telemedicine

As technology becomes more affordable, remote treatment options continue to grow in popularity for both doctors and patients. For the elderly and those living in rural areas, telemedicine provides increased access to healthcare services that otherwise might not be possible, from remote diagnostics and monitoring to medical education and outpatient services. Both public and private payers are also starting to provide increased reimbursement for telemedicine services and state laws are changing to remove restrictions and facilitate the provision of telemedicine services.

Virtual and Augmented Reality

The use of VR and AR technologies will expand in healthcare for medical education and training, surgical support, other types of decision support, and pain management. They can be used for simulation of scenarios, decision support for providers performing procedures, and distraction, education, and entertainment of patients.

These technologies are enabling a variety of new applications in areas such as:

Behavioral Health

Behavioral health conditions are increasingly prevalent and challenging to treat. The insurance industry and self-insured employers recognize that the costs of treating mental health conditions, including depression, are increasing. Although long-term efficacy has yet to be demonstrated for most digital solutions, insurers and employers are increasingly willing to pay for digital behavioral health pilots. It is increasingly reimbursed by Medicare and investors are beginning to fund this sector. The hope is that more engagement and interaction, facilitated by digital technologies, may help patients with depression, anxiety, substance abuse, PTSD, and other behavioral health conditions.

Chronic Disease Care Management

Chronic care interventions use a combination of health, behavioral, and contextual data – such as glucose levels, sleep patterns, weight, food consumption, activity, social factors, time of day, and weather — to improve patient treatment plans. Digital health tools can also be used to improve care team communication and coordination. These applications have demonstrated such compelling clinical efficacy that insurance companies are starting to pay for them because of improved patient outcomes at reduced cost. Pharmaceutical companies are also interested in integrating digital interventions with their drugs to improve outcomes, differentiate their products, and engage directly with patients.

Data Aggregation and Analytics

In the past few years, there has been a dramatic increase in the amount of digitized health data stored in EMRs and ancillary systems, fitness and health data captured from mobile devices and wearables, and genomic data. There are many potential uses for this explosion of new healthcare data. Insurance companies and companies that pay for employees’ health care directly can use additional data to help refine actuarial models. Physicians can use analysis of this data for diagnosis, quality improvement, and decision support. Patients may benefit from the mining of data for predictions of their propensity for acquiring certain health conditions. As a result, real-time alerts and guidance to patients and healthcare providers are becoming more feasible and useful.

New Payer Models

A recent and intriguing area of investment in digital health is in alternative insurance companies. These startups often compete directly with major industry players, which have also been exploring and deploying digital health solutions. However, these new insurance industry entrants have some advantages over the incumbents. These entrants are unencumbered by existing infrastructure and relationships and thus can establish tighter relationships with provider networks and provide more flexibility. They can also build their technology stack from the ground up which enables them to more effectively use digital health data and solutions to target specific, stratified patient groups. Their primary challenge is achieving sufficient scale and differentiation to compete effectively against the larger, more established payers.

Provider Workflow Enhancement

Digital technologies can help give time-constrained healthcare professionals the ability to see more patients in less time, while delivering a better patient experience, by using data analytics for decision support, more efficient workflow, and different forms of mobile communication and collaboration.

Additionally, the cost curve can be shifted by leveraging less expensive resources. Given decision support tools, artificial intelligence, and data analytics, primary care physicians should be able to do some of the work specialists currently do. Nurses and case managers will be able to reduce a physician’s workload, and increasingly, patients will be able to manage their own care at home with mobile devices.

Collectively, these new applications will dramatically transform the delivery of healthcare services.

Recent Investment Trends

According to a recent report from CB Insights, large technology companies are increasingly focusing on investing in new initiatives in the healthcare domain. Since 2012, the top 10 tech corporate players in the US invested $6.2B over 143 healthcare deals according to CB Insights. Deals and funding into the sector with participation from these corporate entities has increased every year since 2012 to hit a high of 41 deals last year and $2.7B in funding, triple the funding total in 2015. In their report, CB Insights summarized the healthcare activities of the major tech companies:

Google

Google is the most active tech corporate investing in healthcare in the United States. Virtually all of its activity has gone through GV. CapitalG, Google’s growth equity fund, has made investments into Oscar Health and Practo Technologies while Google itself has co-founded Calico Life Sciences and acquired Lift Labs. Lift Labs develops a swiveling spoon that makes eating easier for patients with neurodegenerative hand tremors.

Google has not been shy about investing in therapeutics. In addition to Fulcrum Therapeutics, GV has made deals to Magenta Therapeutics, Spero Therapeutics, Arcus Biosciences, and Forty Seven all in the last year. Magenta is working on stem cell transplantation, Spero is focused on bacterial infections, and Arcus Biosciences and Forty Seven develop cancer immunotherapies.

GE

Once focused on lighting and electricity, the modern GE is a multinational conglomerate operating across many sectors. It is also one of the most active healthcare investors among US-based tech corporates. Recently, the company has made deals to HealthReveal, which monitors and predicts adverse health events, EMR data analytics company Arcadia Healthcare Solutions, and primary care provider Iora Health. The largest deal with GE Ventures participation was the $220M Series B of genome sequencing company Human Longevity in 2016.

Apple

Apple has made very few investments in healthcare startups despite diving into the sector internally with services such as HealthKit, CareKit, and ResearchKit. Apple has made two recent acquisitions in the space, however. In August 2016, the company acquired Gliimpse, developers of a personal health data platform, and in May 2017 acquired Beddit, which developed a sleep monitor that tracks heart rate, breathing, snoring, and sleep quality.

Amazon’s only healthcare investments in the past four years have been cancer diagnostics company GRAIL and baby monitoring startup Owlet Baby Care, the latter being backed by the Amazon Alexa Fund. Steve Rabuchin, VP of Amazon Alexa, has stated that the company will integrate Owlet with Alexa. In March of this year, Bezos Expeditions and Amazon participated in GRAIL’s $914M Series B.

Intel

All of Intel’s investments in healthcare startups have gone through its venture arm, Intel Capital. The corporate entity has made two acquisitions in healthcare, Basis Science (2014) and IDesia (2012). Basis Science develops heart rate and activity monitors, while IDesia offers security identification technology based on a person’s unique heartbeat. Intel has participated in numerous rounds to both CareCloud and Sotera Wireless. CareCloud is a provider of cloud-based medical record and billing software, while Sotera Wireless develops wireless devices for in-patient monitoring of blood pressure, heart rate, oxygen saturation, and other biometrics.

Others

Facebook, Amazon, Microsoft, Cisco, and Oracle have all demonstrated limited private market activity in healthcare since 2012. Below are listed a few deals with participation from these corporate entities.

Microsoft has made two healthcare deals since 2012, one from the corporate entity into Advanced Dental Cloud,and one through Microsoft Ventures to Livongo Health. Advanced Dental Cloud makes software for modeling dental implants and Livongo Health combines coaching and connected devices to improve diabetes management.

Oracle has made one acquisition and one equity investment into healthcare startups since 2012. It acquired clinical trial management software provider ClearTrial in 2012 and participated in Proteus Digital Health‘s $45M Series F in 2013. Proteus has raised on four other occasions since then, with no disclosed Oracle participation.

Cisco has made no equity investments in healthcare companies since 2012. The one deal shown on the social graph above refers to a grant made to Teslon in January 2017.

According to CB Insights, funding this year has already reached over $1.5B spread across 18 deals. That’s already more dollars to the sector so far this year than in 2015. At the current run rate, 2017 is on track to reach $4B across 48 deals, a five-year high for tech corporates participating in deals involving healthcare startups. The historical and current participation of these companies in healthcare industry investments is summarized below.

Conclusions

Healthcare is increasingly being impacted and disrupted by digital health innovations. The digital health sector has moved beyond the first wave of simple wellness devices and applications to integrated solutions from companies that are beginning to have a deeper understanding of how technology can be used to make healthcare more effective and efficient. Consumer companies such as Fitbit, Apple, and Samsung are beginning to partner with major payers, providers, and pharmaceutical companies. As shown above, major technology companies are also investing large sums in the healthcare sector to augment their existing products and support new strategic initiatives.

Despite this shift, many experts agree that there are too many companies targeting the same narrow problems. Many digital health founders have come from the technology industry and try to solve a problem that they have personally encountered within the imperfect healthcare system, whether it is truly widespread or not. Others may have just graduated from college and have limited business exposure, let alone any healthcare experience, and don’t understand the relevant use cases very well.

The entrepreneurs who research and fully understand the complexities of this industry — including the relevant use cases, current workflows, the needs of providers and patients, and who will ultimately pay for these innovations — will be far more successful. Regardless of what digital health product or services startups offer, they will need to demonstrate a real value proposition and generate some evidence that outcomes are improved, revenues are increased, or costs are reduced or no one will pay for their solution or expend time and effort trying to integrate it within their existing health IT infrastructure.

I’m an internal medicine physician and a global health specialist. I’ve been with IMO since its founding in 1994. I’m the chief medical officer. I’ve also spent time as president and chief operating officer and I’m a previous board member for the company. I’ve been full time with IMO since the onset of ICD-10-CM and Meaningful Use.

In 2008, I joined Columbia University and the Earth Institute to help Jeffrey Sachs bring health information technology to less-developed countries. We’re trying to achieve the Millennium Development Goals.

IMO started as a computer science department. We evolved electronic health records, which is now being sold as Allscripts Professional. We’ve taken the company from primarily being a consulting firm and a terminology product company to now a solutions company. We recently received a major investment from Warburg Pincus, which is the fifth-largest private equity firm.

My job as chief medical officer is to ensure that the content and lessons that we’ve learned over the last two decades at IMO transfer to our customers and to our vendor partners. IMO partners with most of the EHR vendors. Our installed base covers about three-quarters of the acute and primary care sites in the United States. Over a half-million doctors use us in the US alone.

Our primary mission is to improve care by helping the health information systems capture clinical intent in the most accurate, specific way possible. We’re about paving the semantic highway and driving downstream workflows and secondary use of data.

Coding and terminology drives billing, but what are the patient and societal benefits?

It’s very much about capturing that clinical intent for these downstream processes, including things like population health, risk management, and predictive modeling. We’re trying to improve care as well as bend the cost curve. It’s through capturing the clinical descriptions — what physicians actually think about in their heads – that is so essential to teasing out that value proposition.

Many people think of it in terms of the big chronic disease areas like diabetes, coronary artery disease, and so on, which certainly does have a reimbursement or billing implication. But for trying to improve care, we’re trying to identify exactly the patients who can most benefit from therapy and the most accurate treatment possible.

Using the high level of granularity that clinicians have to take care of their patients can be used probably even more for driving the identification of high-risk patient groups or specific patients who will benefit from treatment, therefore significantly improving the quality of care.

Assuming that providers are willing and able to physically exchange information, what terminology and semantic interoperability problems remain?

That’s one of the areas that people have often missed in the strive to develop the electronic data interchange part, but not necessarily the semantic interoperability part.

What we’ve seen is that as information tends to move around the health information system ecosystems across enterprises, a lot of that semantic fidelity gets lost. Systems have been designed primarily to support single-term, single-code relationships. With FHIR and CCDA, where more information is going to be transferred, if that fidelity is not maintained, there’s a lot of loss of good data and the ability to act on it.

One of the things that IMO has worked pretty hard on is to first initially capture that clinical intent, but then ensure that it’s maintained as information moves around the health ecosystems. As a matter of fact, IMO has been working with the Structured Documents Group of HL7 to ensure that there’s an approved method of sending the IMO lexical identifier within all of those interoperability messages — whether it’s CCDA or FHIR — to ensure that the full color is not lost.

IMO’s terminology frequently has more than one reference map, whether it’s SNOMED, ICD, or LOINC. We have about 80 maps that come off of our clinical interface terms that ensure that all of those terms are maintained as information moves through the ecosystem.

What’s the best solution for codifying information for specific purposes while retaining the patient narrative to avoid losing the underlying context?

Over the last 20 years, there’s been a lot of lessons learned about forcing physicians into structured data collection. We have the scars on our backs to remember those lessons.

There is a balance between structured and unstructured, although it’s a little bit of a false dichotomy. If you focus on capturing clinical intent and using interface terminology, it should be possible — through structured data and unstructured data — to capture the right content in a clinically granular way.

We work closely with many natural language processing companies to ensure that those engines are able to identify these pre-coordinated or highly physician-friendly terms within both narrative, unstructured text as well as structured text. It’s a key thing to remember that it’s not always in the places that we expect to find that information, where key information will be determined.

There has to be a balance between maintaining the full clinical story in the narrative text as well as the highly codified structured text.

Should clinicians have the ability to electronically highlight the structured or unstructured information that they find most useful so that a colleague covering that patient or receiving a referral could make quick sense of a patient’s chart?

That’s a difficult question. That assumes that the information that clinicians are dealing with within the health information systems is hard to decipher and that their information is not clearly available or can be recognized quickly.

This is something that we’ve been working on a lot. How to organize the data now that we’ve collected it in such a clinically-friendly, granular way. How to then semantically group that to drive various kinds of workloads. How to visualize the problems or the information in the record in a way that’s most relevant to me as a provider, based on my specialty and my experience with that patient. Trying to not lose information that may not be as relevant, but organize it in such a way that it doesn’t distract me, but it also doesn’t hide things that I might be interested in in the medical record.

That’s a real challenge. We don’t always know what is going to be the most relevant for you in the record.

Also, as you start to semantically organize and group things together, you’re going to use that information to drive all sorts of downstream workflows. Things like clinical decision support, which hopefully will help prompt providers for things that they shouldn’t overlook or that would be most relevant to them. As well as driving quality improvement programs, population health, clinical research, and so on.

IMO is spending a lot of time in developing those services. It’s not just about tagging things in the medical record, but about using those tags meaningfully to help organize the data in a better way.

Are patients receiving the expected benefits from the migration to ICD-10?

ICD-10 certainly was a huge burden in the transformation from ICD-9. The 80,000 or so codes added would have normally been a disaster for many providers to deal with.

Most people don’t have to deal directly with the ICD-10-CM codes, so it’s not so much those codes that are improving patients. It’s the clinical concepts and the clinical terminology that are really most relevant to providers and t patients.

There’s no question that the evolution to more granular coding systems will benefit both patients and providers by giving more specific care and being able to perhaps group or subset patients based on more granular concepts. ICD-11 and SNOMED CT are looking to be much more closely integrated so that those two use cases — the billing use case and the secondary use case — will overlap.

That’s going to take a long time, for us in the US in particular, to move to. In the interim, it’s up to vendors like ourselves to try to focus on the level of granularity and information that is most needed by the providers and for the patients. That will improve the quality of care.

You have a background in public health and global social causes, having served as president of Physicians for Social Responsibility. What optimism can you offer in looking at the US healthcare system and our social policy when it’s so easy to find negatives?

There’s an interesting parallel. For me, if we want to get the most value from data — whether it’s big data or small data — it’s about accurately capturing what’s happening with the patient. What we currently suffer from is a distorted view of that reality. Everything that we’ve been trying to do — whether it’s our clinical decision support dashboards or health information technology in general – it’s just not going to perform well if we can’t see the world clearly.

IMO and other organizations are trying to facilitate patient-doctor communication to accurately capture and see the world. It’s through that joint solution that we can transform healthcare.

For me, for someone who’s so active in trying to save the world from global poverty, climate change, and nuclear war, healthcare is actually the easy part. If we establish that pattern of behavior — the ability to share information clearly and focus on solving the problems — we could use that technology and the lessons we’ve learned from working together globally to solve these other grave threats to our society.

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